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�_ ��� <br /> � NIISCELL�AN�OUS RECORD V <br /> 29058-THEAUGUSTINECO.ORANDISLAND,NEBR. , <br /> � <br /> CERTIFICATE OF DEATH <br /> STATE OF NEBRASKA <br /> _ DEPABTMERTT 0�'. HEALTH <br /> Bureau of V�.tal Statistics <br /> STANDARD CERTIFICATE OF DEATH <br /> DEPARTMENT OF COMMERCE <br /> BUREAU OF THE CENSUS. aocial Sacurity No. ------- State File No. ?270 <br /> l. PLACE �F DEATH: <br /> (a) County Buffalo <br /> (b) City or town Shelton <br /> (c) 1Vame of hospital or institution: <br /> 2. USUAL RESTDENCE OF DECEASED: <br /> (a� State NebPaska (b) County Buffalo <br /> (e) Ci�y or town Shelton <br /> (d) Stree� No. - - - - - - - - - - - - - - - - <br /> w-b5o <br /> (e) If foreign born, how long in U. S. A. ? --------years. <br /> 3. (a) �ULL NANiE Eu ene C. W'a.rren <br /> 3. (b) �fveteran namewar - - - - - - - - - - - - <br /> I �. Sex Male <br /> 5. Color or race 3te <br /> 6. (a) Single, widowed,married divorced Married. <br /> � 6. (b) Name of husband or wife Ma.ude Warren <br /> 6. (c � Age of husband or wife, if alive 60 �rrss <br /> 7. Birth date of deceased Mar. _ 29__1969 <br /> 8. AGE: Ye�rs ,� Months 23ays 21 if 3ess than one day -----h�. --- min�--- <br /> 9. Birthplace 3outh Schroon,' New York. <br /> 10. Ugual occupation re�ired <br /> 11. Industry or businesa --------- <br /> Father 12. Name Aaron Warren <br /> I 13. Birthplace South Sehroon, N. Y. <br /> Mother 1�. Maiden na,me Frances Rusa <br /> 15. Birthplace --------------------------- <br /> 1b. (a) Informant� s own signature Maude �larren <br /> (b) Address Shsl�can, Nebr. , <br /> i7. (a� Buf�ial,cre�aa.��on` or. °:removal) burial (b) Date thereof Aug. 23 -�6 <br /> (e) P1ace: burial or cremation Bhelton, Cemeter� <br /> 1$. (a) Signature af funeral director W. E. Amos <br /> 19. (a� Au . 2 1 �6. (b) C. C. Reed <br /> Date received local Registrar� s S�.gnature) <br /> registrar <br /> MEDICAL CERTTF'ICATION <br /> 20. Date of death: Month Au st day 20 19�6 <br /> hour minute � A.M. <br /> 21. I hereby certify that rattended �he deceased from June 30, 19�6 to --------- lg-- <br /> that I last eaw him al.ive on �u�. 19, 1946; and �ha� death oecured on the day and <br /> hour stated above. <br /> I med e cause of death ----- Uremia (w�th Amurio) 1 mo. <br /> m iat <br /> Due to Nephritis Chronic Years <br /> 'D�.e to Myz^�a�etis Chronic Yeara <br />� Other conditions Diabetes Mellitus <br /> Ma�or findings PHYSICiAN Underline the eaude �� <br /> I' Of opera'�ions -------------- which death should be charged <br /> Of autopay - - - - - - - - -- statiatically. <br /> 22. If death were due to external causee, fill in the following: <br /> (a) Accident, suiclde, or homicide (specify) <br />, (b) Where did in�ury oecur? <br /> (d) Dia in,�ury occur in or about home, on far�, in industrial place, fn pub�ic plaee? <br /> While at work7------- (e) Means of in�ury --------- <br /> 23. Signature ----- L. W. El�rood (M.D. or other ------" <br /> Addreas 8helton, Nebr. Date signed 8/22/�6 <br /> 25. I hereby eertify I personally embalmed the body of the deeeased named hereon <br /> W. E. Amos L�.cense No. ].067 <br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL CER'FTFICATIDN ON FILE WITH <br /> THE STATE DEP,ARTMENT OF HEALTH,BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEP�SITORY <br /> DfJR VITAL RECORDS. <br /> (CORP} , W. 8. Petty, M.D. <br /> (SEAL) �irector of Hea3.th and <br /> State Registrar. <br /> Lincoln,Nebraska <br /> geb. 2 19�7 <br /> Filed for record this 2'� day of February, 1g�7, at 9:00 o�clock A. . . <br /> Register of D,eed <br /> ��-o-a-o-o-o-o-�-o-o-o-a-o-o-o-o-a-o-o-o-o-o-o-o-o-o-o-o-o-o-a-o-o-o-o-o-o-o-o-o-o-o-o-o-o <br /> � <br /> ' <br />� <br /> i <br />